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Community Blue Medicare PPO Premier (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Blue Medicare PPO Premier (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Community Blue Medicare PPO Premier (PPO) in 2025, please refer to our full plan details page.
Community Blue Medicare PPO Premier (PPO) is a PPO plan offered by Highmark Health available for enrollment in 2025 to people living in North Central PA. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Community Blue Medicare PPO Premier (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Community Blue Medicare PPO Premier (PPO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Community Blue Medicare PPO Premier (PPO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $55.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $8950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $8950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Community Blue Medicare PPO Premier (PPO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy. For example, you'll pay no copay for preferred generic drugs at a preferred pharmacy, while standard generic drugs have a 25% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for covered drugs. This plan offers an enhanced alternative drug benefit. The monthly premium for Part D is $35.40, but may be reduced if you qualify for the low-income subsidy.
Additional Benefits
The Community Blue Medicare PPO Premier (PPO) plan offers a range of benefits, including coverage for inpatient and outpatient hospital services, with varying copays depending on the service. You'll find coverage for primary care, preventive, hearing, vision, and dental services, each with specific copays or maximum benefits. Additional benefits include home health services with no copay, and coverage for ambulance, emergency, and skilled nursing facility services, with applicable copays and coinsurance.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $250 copay per admission for a Medicare-covered stay, and no copay for additional days. Inpatient Hospital Psychiatric has a $425 copay for days 1-3, and no copay for days 4-90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital and observation services have a $245 copay, ambulatory surgical center services have a $175 copay, and individual and group sessions for outpatient substance abuse have a copay between $45 and $45.
Partial Hospitalization See details
Partial hospitalization is covered by the Community Blue Medicare PPO Premier (PPO) plan.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Community Blue Medicare PPO Premier (PPO) plan. Ground and air ambulance services have a $260 copay, with no coinsurance. Transportation Services to a plan-approved health-related location are covered, while transportation to any other health-related location is not covered.
Emergency Services See details
Emergency Services are covered by the Community Blue Medicare PPO Premier (PPO) plan, with a $125 copay and no coinsurance, and if admitted to the hospital, the copay is waived if admission occurs within 3 days; Urgently Needed Services have a $15 copay and no coinsurance; Worldwide Emergency Services, Worldwide Emergency Coverage, have a $125 copay and no coinsurance; Worldwide Urgent Coverage has a $15 copay and no coinsurance, and Worldwide Emergency Transportation has a $260 copay and no coinsurance.
Primary Care See details
The Community Blue Medicare PPO Premier (PPO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services, physician specialist services, mental health specialty services with a $30 copay for individual and group sessions, podiatry services, psychiatric services with a $30 copay for individual and group sessions, physical therapy and speech-language pathology services, additional telehealth benefits with a $0 - $45 copay, and opioid treatment program services with a $45 copay. Chiropractic services require prior authorization, and individual and group sessions for mental health and psychiatric services have a minimum and maximum copay of $30.
Preventive Services See details
Preventive services include coverage for Medicare-covered preventive services, annual physical exams, and other preventive services. Additional preventive services have coinsurance, and home and bathroom safety devices and modifications have 20% coinsurance.
Hearing Services See details
Community Blue Medicare PPO Premier (PPO) covers hearing exams and prescription hearing aids, with routine hearing exams covered for one visit per year. Prescription hearing aids have a maximum benefit of $500 per year, with a copay between $699 and $999 for all types of hearing aids. Fitting/evaluation for hearing aids, prescription hearing aids for the inner and outer ear, and OTC hearing aids are not covered.
Vision Services See details
The Community Blue Medicare PPO Premier (PPO) plan covers vision services, including routine eye exams with one visit per year. Eyewear is covered with a combined maximum benefit of $400.00 per year for both in-network and out-of-network services, and contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Community Blue Medicare PPO Premier (PPO) covers dental services with a maximum benefit of $3,000 per year, including oral exams (1 visit every six months), dental x-rays (1 visit per year), prophylaxis (cleaning) (1 visit every six months), and fluoride treatments (1 visit every six months). The plan does not cover maxillofacial prosthetics, implant services, or orthodontics, and has limitations on other services such as endodontics and periodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Community Blue Medicare PPO Premier (PPO) plan. You will pay 20% coinsurance.
Medical Equipment See details
Medical equipment benefits are covered, including durable medical equipment (DME) with 20% coinsurance and no copay, prosthetics/medical supplies with 20% coinsurance and no copay, and diabetic equipment. Diabetic supplies have a coinsurance between 0-20%, and diabetic therapeutic shoes/inserts have a 20% coinsurance; both have no copay. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, although Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $150, Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Community Blue Medicare PPO Premier (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Community Blue Medicare PPO Premier (PPO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, there is a $214 copay.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, which are covered up to a maximum of $185 every three months. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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